Surgery for Obesity and Related Diseases 8 (2012) e21–e26 ASMBS online statements/guidelines Updated position statement on sleeve gastrectomy as a bariatric procedure ASMBS Clinical Issues Committee Revised March 14, 2012 Preamble small bowel. The metabolic mechanisms of action of SG continue to be an active area of research. The American Society for Metabolic and Bariatric Surgery The recommendations of the 2009 position statement (ASMBS) has previously published 2 position statements on regarding the use of SG as a bariatric procedure were the use of sleeve gastrectomy (SG) as a bariatric procedure primarily based on a systematic review of the published data [1,2]. These position statements were developed in response to completed at that time. These included 2 randomized con- inquiries made to the ASMBS by patients, physicians, hospi- trolled trials, 1 nonrandomized matched cohort analysis, and tals, health insurance payers, the media, and others regarding 33 uncontrolled case series. At that time, the reported over- new procedures or issues within our specialty that require close all mean percentage of excess weight loss (%EWL) after SG evaluation and evidence-based scrutiny. In the evolving field was 55% (average follow-up of Ͻ3 yr), and the complica- of bariatric surgery, it is periodically necessary to provide up- tion rates in large single-center series (n Ͼ100) ranged dated position statements based on a growing or changing body of Յ15%. The reported leak, bleeding, and stricture rate in the evidence. The Clinical Issues Committee and Executive Council systematic review (which included high-risk patients) was have determined that since the 2009 position statement on SG was 2.2%, 1.2%, and .63%, respectively, and the postoperative issued, substantial changes have been published regarding SG and 30-day mortality rate was .19% in the published studies. that the number and quality of the publications evaluating SG An updated search of the published data using the same warrant publication of an updated statement. Specifically, multiple search strategy (MEDLINE search using key words “bari- studies evaluating co-morbidity improvement after SG, compar- atric, sleeve, gastrectomy, vertical gastrectomy”) was con- ative studies with other accepted bariatric procedures, and ducted for the present updated statement. Case reports or long-term outcome data have emerged since the 2009 position small case series (Ͻ10 patients), review articles, and studies statement. Recommendations are made based on published, peer- that included adolescents or combined SG with other pro- reviewed scientific evidence and expert opinion. The statement is cedures were not included in the present analysis. The not intended as, and should not be construed as, stating or estab- updated search revealed 69 studies published since the pre- lishing a local, regional, or national standard of care for any vious position statement that provide relevant outcome data bariatric procedure. to support updated recommendations [3–71]. These new data include several randomized controlled trials that gen- erally show equivalence or superiority of the laparoscopic The data SG (LSG) to currently accepted procedures (Roux-en-Y The bariatric procedure commonly referred to as “sleeve gastric bypass [RYGB] and laparoscopic adjustable gastric gastrectomy” is a left partial gastrectomy of the fundus and banding [LAGB]) with short- and medium-term follow-up body to create a long, tubular gastric conduit constructed periods. The randomized controlled trials, the reported along the lesser curve of the stomach. This procedure has weight loss outcomes, and a summary of the conclusions evolved from a larger gastric component of the duodenal from these studies are listed in Table 1. In addition to the switch with biliopancreatic diversion. Although SG is gen- randomized trials listed, several matched-cohort, prospec- erally considered a restrictive procedure, the mechanisms of tive, and case-control studies have demonstrate weight loss weight loss and improvement in co-morbidities seen after outcomes, diabetes remission rates, improvements in in- SG could also be related to neurohumoral changes related to flammatory markers and cardiovascular risk, and improve- gastric resection or expedited nutrient transport into the ments in a variety of obesity-related co-morbidities after SG 1550-7289/12/$ – see front matter © 2012 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2012.02.001 e22 ASMBS Clinical Issues Committee / Surgery for Obesity and Related Diseases 8 (2012) e21–e26 Table 1 Randomized trials evaluating sleeve gastrectomy Investigator Procedures (n) Mean preoperative Follow-up Weight loss Conclusions BMI (kg/m2) (mo) Woelnerhanssen et al. [71] LSG (11) LSG: 45 12 LSG: 28% TBW No differences in weight loss, LRYGB (12) LRYGB: 47 LRYGB: 35% TBW insulin sensitivity, or effects on adipokines (adiponectin, leptin) Kehagias et al. [42] LSG (30) LSG: 46 36 LSG: 68% EWL No differences in weight loss; LRYGB (30) LRYGB: 45 LRYGB: 62% EWL LSG and LRYGB equally safe and effective in amelioration of co-morbidities; LSG associated with fewer postoperative metabolic deficiencies Lee et al. [74] LSG (30) LSG: 30 12 LSG: 76% EWL GB patients more likely to Mini-GB (30) LRYGB: 30 Mini-GB: 94% EWL* achieve remission of T2DM (HbA1c Ͻ6.5%, 93% versus 47%, P ϭ .02) Karamanakos et al. [72] LSG (16) LSG: 45 12 LSG: 69% EWL Greater weight loss with SG LRYGB (16) LRYGB: 46 LRYGB: 60% EWL† at 1 yr; PYY levels increased similarly after either procedure; greater ghrelin reduction and appetite suppression after LSG than after LRYGB Himpens et al. [73] LSG (40) LSG: 39 36 LSG: 66% EWL Weight loss and loss of LAGB (40) LAGB: 37 LAGB: 48% EWL* feeling of hunger after 1 yr and 3 yr better after LSG than LAGB; GERD more frequent at 1 yr after LSG and 3 yr after LAGB Peterli et al. [58] LSG (14) LSG: 46 3 LSG: 39% EBMIL Both procedures markedly LRYGB (13) LRYGB: 47 LRYGB: 43% EBMIL† improved glucose homeostasis; insulin, GLP- 1, and PYY levels increased similarly after either procedure BMI ϭ body mass index; LSG ϭ laparoscopic sleeve gastrectomy; LRYGB ϭ laparoscopic Roux-en-Y gastric bypass; TBW ϭ total body weight; mini-GB ϭ mini-gastric bypass; EWL ϭ excess weight loss; T2DM ϭ type 2 diabetes mellitus; HbA1c ϭ glycosylated hemoglobin; PYY ϭ peptide YY; LAGB ϭ laparoscopic adjustable gastric band; GERD ϭ gastroesophageal reflux disease; EBMIL ϭ excess BMI loss; GLP-1 ϭ glucagon-like peptide-1. *Pϭ NS. † P Յ .05. that are equivalent to or exceed those of RYGB and LAGB to weight loss, co-morbidity reduction, or diabetes remission [12,13,51,55]. The remission rates of type 2 diabetes after [22,31,39], randomized studies have demonstrated superiority SG are typically reported between 60% and 80%, depend- or equality to RYGB [42,72] and superiority of LSG over ing on the patient population and length of follow-up LAGB in terms of weight loss (%EWL 66% versus 48%), [3,9,24,33,45,55,58,61,67,69]. A systematic review of dia- co-morbidity reduction, or diabetes remission [73]. betes remission rates after SG included 27 studies and 673 A review of published complications after SG demon- patients [33]. At a mean follow-up of 13 months, diabetes strated major complication rates that are equal to or less had resolved in 66% of patients and improved in 27%. than those reported in the 2009 statement, and no new There was a mean decrease in blood glucose of Ϫ88 mg/dL safety concerns have emerged. Staple line leaks and and a mean decrease in glycosylated hemoglobin of Ϫ1.7%. bleeding after SG continue to be the most serious com- In addition to improvement in many clinical parameters, plications and occur in 1–3% of patients in large pub- several studies have also demonstrated significant improve- lished series [8,11,29,54,60,68]. ments in quality of life after SG [6,19,26,41,44,65]. The development of gastroesophageal reflux disease Although several case-control and retrospective series that after SG has been reported in several publications have demonstrated superiority of RYGB over SG with regard [20,37,43,48], but a recent systematic review evaluating the Updated Position Statement on SG / Surgery for Obesity and Related Diseases 8 (2012) e21–e26 e23 effect of SG on gastroesophageal reflux disease reported BMI loss at 12 and 24 months. In this patient population, inconsistent outcomes [21]. Additional studies of the long- diabetes remitted in 81% of the patients and hypertension term effects of SG on gastroesophageal reflux disease symp- improved in 63.2%. A second-stage surgery was performed toms and the role of SG for patients with hiatal hernia are in 18 patients (3.2%) [63]. necessary to draw more definitive conclusions. There are Data from the Third International Summit for Sleeve also studies that report SG results in fewer nutritional defi- Gastrectomy was recently published and included question- ciencies than those reported after gastric bypass [32,35]; naire results from 88 surgeons who had performed 19,605 however, there is insufficient evidence to draw any defini- SG procedures. Among this group of patients, a second- tive conclusions, and more evidence is needed regarding the stage procedure became necessary in 2.2% of patients. The effect of SG on long-term vitamin, mineral, and nutritional mean percentage of excess weight loss reported by the deficiencies. surgeons at 1, 2, 3, 4, and 5 years was 62.7%, 64.7%, Several large registries have also reported weight loss 64.0%, 57.3%, and 60.0%, respectively. Proximal staple and complication data after SG. The American College of line leaks occurred in 1.3% of cases (range 0–10%), and Surgeons Bariatric Surgery Center Network longitudinal distal staple line leaks occurred in .5%.